Clinical Innovators | Putting Prevention First: An Interview with Janet Wright, MD

By Amol S. Navathe, MD, PhD

Janet Wright, MD, is the executive director of Million Hearts®, a national initiative launched by the Department of Health and Human Services in September 2011 with the goal of preventing 1 million myocardial infarctions and strokes by 2017. Dr. Wright received her medical degree from the University of Tennessee and completed her internal medicine internship and residency at San Francisco's Children's Hospital and Adult Medical Center and cardiovascular fellowship at the University of California San Francisco. After 23 years of clinical practice at Northstate Cardiology Consultants, Dr. Wright served 3 years as Senior Vice President of Science and Quality at the ACC. She also served on the ACC's Board of Trustees and chaired the Task Force on Performance Assessment, Recognition, Reinforcement, Reward and Reporting. Dr. Wright joined Million Hearts in 2011.

In 2014, we are hitting the midway point for the Million Hearts initiative. What are the most important actions Million Hearts is promoting right now?
To help reach the goal of preventing 1 million hearts attacks and strokes by 2017, Million Hearts identified three strategic directions for partners and stakeholders for 2014 and beyond:

  • Send a clear signal that MIs and stroke are preventable. Many people still think that heart attacks are inevitable—that they are the family fate. We are asking all our partners to focus on the five most powerful actions their members or audiences can take to re-write the family story. We know from high performers around the country that excellence in the ABCS (Aspirin when appropriate, Blood pressure control, Cholesterol management, and Smoking cessation) is achievable. Now we need to make that excellence go national.
  • Measure and report progress on heart disease and stroke prevention. This will help accelerate the pace of progress, engage partners in meaningful work, and inform course corrections. Local, state, and national dashboards or other reports that show progress can motivate others to join and pave the way for rapid cycle improvement.
  • Detect. Connect. Control. In order to protect, preserve, and improve cardiovascular health, we need to find those at risk and connect them to clinical care and to community resources to control hypertension, address aspirin use, manage cholesterol, and quit smoking.

The Million Hearts initiative set out with the focused goal of preventing 1 million heart attacks and strokes by January 2017. What kind of progress has been made thus far?
Million Hearts has made tremendous progress in addressing unnecessary illness and deaths from heart attack and stroke by defining the most important actions that individuals, clinical practices, and health care systems can take, and in changing the environment within communities.

We are working hard to quantify that progress. In 2014, Million Hearts will have preliminary data from 2012 that will establish the baseline from which we'll measure progress, and then progress in events prevented will be shared quarterly. Data sources include:

  • Progress on the ABCS every 1-2 years from national surveillance and surveys
  • Vital statistics for cardiovascular mortality and estimates of cardiovascular events from the Agency for Healthcare Research and Quality's Healthcare Cost & Utilization Project
  • Centers for Medicare & Medicaid Services data showing hospital discharges for heart attack and stroke
  • Reports from our partners across the country

The Million Hearts initiative has brought the worlds of public health and clinical medicine together in service of a common goal. How might other fields of medicine utilize this framework? One of the most important tasks of Million Hearts is integrating complementary assets from the often-separate worlds of public health and health care to achieve this awesome goal. We are working with partners to implement systematic approaches into clinical care settings and to mobilize community experts and other resources to support and effect behavior change.

For example, we know that simple, evidence-based treatment protocols can have a powerful impact in improving blood pressure control. Some of those protocols include clarifying titration intervals and treatment options; expanding the types of staff that can assist in timely follow-up with patients; and, when embedded in electronic health records, serving as clinical decision support at the point of care so no opportunities are missed to achieve control.

Cheshire Medical Center (CMC), a health care system in Cheshire County, New Hampshire, was able to increase its hypertension control rate, moving from 72.6% at the beginning of 2012 to 84.4% by July 31, 2013, by implementing a number of systematic approaches in their clinical setting and using partners in the community to help educate their patients about heart disease and stroke prevention. In support of Cheshire County's goal to become the healthiest community in America by 2020, CMC created a Hypertension Quality Improvement Team to establish a consistent approach to high blood pressure control across practice areas. They maintained a free nurse-led clinic to measure blood pressure and coordinated with health care professionals to schedule follow-up visits for patients struggling with high blood pressure. CMC also mobilized partners in the community to disseminate wallet cards to track blood pressure and other important numbers. This allowed patients to see the same information anywhere they went in the county.

The concept of adopting and following evidence-based models of care and working with the community to support and effect behavior change can be applied to many other fields of medicine. It reduces the chances of missing important risk factors or flags, especially when these models of care incorporate team-based care and community-clinical links to increase the opportunities for patients to improve their cardiovascular health where they live, work, and play.

What lessons from your clinical work have you been able to use to inform policy decisions?
I practiced cardiology for just over 2 decades and for most of those years, I performed catheterizations and interventions. I was a poor change agent for my patients, and I could often identify people on a first visit that I knew I would meet in a cath lab in the middle of the night. Although my entreaties about weight loss, medication adherence, and smoking cessation were not consistently effective, I had an ace in the hole: the team in cardiac rehab and the nurse practitioners who came to work with us in the later years of my practice. Their contributions to healthier habits and long-term prevention were powerful and more likely to change behavior than an emergency angioplasty or bypass procedure. I became much more interested in the hard thing, the simple and small but daily change that can create health over time. And I became very interested in the systems and policy changes that would be necessary to help patients get and stay healthy.

What is being done from a public health perspective to reach the goals of the Million Hearts initiative? What is being done from a clinical perspective?
In order to prevent a million heart attacks and strokes, we know there is work to be done in changing the environment and improving outcomes for patients.

To change the environment, Million Hearts is focusing on increasing smoke-free environments, increasing the availability of lower sodium choices, and eliminating trans fats. The FDA made a preliminary determination that partially hydrogenated oils—the primary contributor of artificial trans fats in our diet—are no longer "Generally Recognized as Safe," which means there would be restrictions on their uses and/or levels. Eliminating trans fats from the food supply could prevent 20,000 heart attacks and 7,000 deaths per year.

To improve performance in cardiovascular disease prevention, we are asking health care professionals and the systems in which they work to prioritize the ABCS system, harness the power of health information technology to improve health outcomes, and participate in new models of care that recognize and reward outcomes and value.

A major emphasis of Million Hearts is to promote a focused set of clinical quality measures for ABCS and align these measures across public and private reporting initiatives. This means that professionals adopt and report on measures that matter for their patients and that they can measure once and report to all.

We are focusing on hypertension control due to its prevalence, impact on outcomes, and current less-than-optimal control rate of about 50%. We have learned that high-performing practices use evidence-based treatment protocols that serve as a playbook or script for all team members. They also invest in training their patients in self-measured blood pressure monitoring and use those readings to inform decision making. Our Million Hearts Hypertension Control Champions have generously shared their best practices and continue to set a high bar for others—and themselves.

We are working to harness the power of health information technology by promoting the use of evidence-based clinical decision support tools to alert clinicians of gaps in care while the patient is still in the office.

The new models of care that recognize and reward outcomes serve as an opportunity to work in teams and across settings to achieve the results that are most desired by patients and professionals alike.

Where are we falling short on evidence-based interventions? How can we translate awareness into action?
In cardiovascular disease prevention, we all know what works but we do not always have the systems in place or the community connections we need to help achieve the results we seek. The challenge is implementation. That is the reason that we are sending a clear signal that everyone has a role to play in preventing MIs and stroke. We are identifying the top five most powerful actions to be taken by individuals, public health and community organizations, health care professionals and systems, and payers and employers.

Million Hearts is a 5-year initiative and our goal is to prevent a million or more events, but also to invest in changes that will return far more than a million over time. It is our responsibility to share evidence-based, impactful strategies and interventions along with implementation guidance and strong examples in order to reduce the activation energy for our partners.

We offer resources to assist partners and others in these actions and recognize achievement and improvement to build additional momentum.

How can clinicians become more effective agents of change in the context of a demanding flow of care?
As I mentioned earlier, we believe the single, most important thing that a clinician can do to prevent heart attacks and strokes is to set up the teams, technology, and processes to help patients achieve excellence in the ABCS system. It takes a well-oiled team machine—the physician, advanced practice nurse, physician assistant, nurse, hospital, community pharmacist, medical assistant, care coordinator, and most importantly, the patient and family—to adopt and maintain medication adherence, self-monitoring, and other healthy habits. Although the demands of daily, and nightly, care are huge, an investment now in excellence in the ABCS system will have an almost immediate and long-lasting impact on outcomes for patients.

Amol S. Navathe, MD, PhD, is a physician at Brigham and Women's Hospital, a clinical fellow at Harvard Medical School, and adjunct faculty member at the Leonard Davis Institute of Health Economics of the Wharton School of Business, University of Pennsylvania. Dr. Navathe is also the co-Editor-in-Chief of Health Care: The Journal of Delivery Science and Innovation.

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